: : : : Quantity (MT) Rate (Rs./MT) Total Assessable Value in (Rs.)

GRAND TOTALAmount in Words : Excise duty in Words :

Sl. No. & Date of Debit entry in PLA/RG23A Part-II/RG23C Part-II :

Declaration : Certified that the particulars given above are true and correct and the amount indicated represents the price actually charged and that there is no flow of additional consideration directly or indirectly from the Buyer. Terms : 1. All disputes subject to Kaikalur Jurisdiction only. 2. Goods once sold will not be taken or exchanged. 3. If payment is not made within seven days interest will be charged @24% p.a.,

For

Dolphin Polymers

Documents Routed thru :

Checked by

Authorised Signatory

ORIGINAL FOR BUYER

DUPLICATE FOR TRANSPORTER TRIPLICATE FOR ASSESSEE QUADRUPLICATE FOR F&A / NOT FOR CENVAT QUINTYPLICATE FOR CTD COPY / NOT FOR CENVAT